Untitled spreadsheet - Sheet1 (3) Flashcards
What is evidence-based decision making (EBDM)?
Process for identifying and using most up-to-date (and relevant) evidence to inform decisions for individual patient problems
What does EBDM involve? (4 key aspects)
- Patient preferences
Why is decision making in medicine important?
- Doctors make decisions constantly
Why do we need EBDM?
- Limited time to read
What are the different types of research studies and when are they each appropriate? (6 main types)
- Cohort studies - prognosis, cause
What is the process of EBDM? (5 steps)
- Converting the need for information into an answerable question
What are the 4 steps in the approach to smoking cessation?
- Health education and general information to enhance motivation for quitting (light smokers)
What is antibiotic resistance?
Bacteria change so antibiotics no longer work in people who need them to treat infections
What are the reasons for the widespread use of antibiotics? (2 reasons)
- Increase in global availability
What are some of the causes of antibiotic resistance? (5 causes)
- Use in livestock for growth promotion
How can antibiotic resistance be prevented? (5 ways)
- Using antibiotics only when prescribed by a doctor
Which factors influence infection? (5 main factors)
- Infectious agents - ability to reproduce, survival, ability to spread, infectivity, pathogenicity
What are the most important infectious diseases in the UK? (9 diseases)
- Diphtheria
What are the most important infectious diseases in developing countries? (4 diseases)
- Pneumonia
What is surveillance?
Systematic collection, collation and analysis of data and dissemination of the results so that appropriate control measures can be taken
What is the purpose of surveillance? (3 main points)
- Serve as an early warning system for impending public health emergencies
Which infectious disease are becoming more common in the UK and why?
Hospital acquired infections (e.g. MRSA, STIs, mumps)
Which infectious diseases are associated with exposure to healthcare?
- Nosocomial infections
What can be done to reduce the risk of nosocomial infections? (3 main steps)
- Prevention - hand washing, infection control programmes, advisory service, surveillance (mandatory for MRSA), sterilisation and decontamination of instruments
What is global health?
- Health of global population
What is international health?
Health defined by geography (nation wealth), problems (e.g. infections, water sanitation), instruments (e.g. infection control aid), and a recipient and donor relationship
What are the major functions of global health? (4 key points)
- To provide health-related public goods - research, standards, guidelines
What is the motivation for global health? (2 key aspects)
- Increased awareness of global health disputes
What is the ‘90/10 gap’ (commission on health research for development - 1990)?
Less than 10% of worldwide resources devoted to health research were put towards health in developing countries, where over 90% of all preventable deaths worldwide occurred
What is the solution for the ‘90/10 gap’? (4 steps)
- Regulation of the quality of imported food, medicines, manufactured goods, and inputs
What impact has travel and migration had on diseases seen in the UK? (5 impacts)
- Help spread infectious diseases
What is WHOs definition of environment, in relation to health?
- All the physical, chemical and biological factors external to a person, and all the related behaviours
What is an outbreak?
Sudden increase in occurrences of a disease in a community, which has never experienced the disease before or when causes of the disease occur in numbers greater than expected in a defined area
What is an epidemic?
Occurrence of a group of illnesses of similar nature and derived from a common source, in excess of what would be normally expected in a community or region
What is a pandemic?
Worldwide epidemic (outbreak -> epidemic -> pandemic)
How can we prevent epidemics? (5 steps)
- Insure developing countries against the threat of a pandemic
What is the role of WHO in public health? (6 key aspects)
- Providing leadership on matters critical to health and engaging in partnerships where joint action is needed
What general intervention strategies are possible for HIV/AIDS? (6 strategies)
- Introduction of blood donor and product screening
What are the determinants of effective outcomes of intervention? (3 main determinants)
- Economics - many developing countries can only spend a few dollars per annum per capita on healthcare
What are the current problems and issues?
- Africa struggles against debt, trade restrictions and inadequate aid provisions
What are the public health objectives of vaccination? (7 objectives)
- To reduce mortality and morbidity from vaccine preventable infections
What are the 2 most effective developments in healthcare to protect population health?
- Clean drinking water
What factors influence the utility of immunisation/vaccination as an approach to disease prevention? (9 points)
- Disease burden
What is required for a disease to be eradicate using vaccination? (3 requirements)
- Where no other reservoirs of the infection exist in animals or environment
Give examples of diseases that have been eradicated
- Smallpox
What is herd immunity?
- Level of immunity in the population which protects the whole population
What is R0?
- Basic reproduction rate
What factors affect R0? (3 main factors)
- The rate of contacts in the host population
What is effective reproduction rate (R)?
Estimates the average number of secondary cases per infectious case in a population made up of both susceptible and non-susceptible hosts
What is the equation for effective reproduction rate?
R = R0x (x is the fraction of the host population which is susceptible e.g. half population is 0.5)
What is the equation for herd immunity?
H = (R0 -1) / R0
What is a susceptible population? (4 key points)
- Any person who is not immune to a particular pathogen is said to be susceptible
What is WHOs role in vaccination?
- Makes recommendations for countries on vaccination policy
List some international immunisation programmes
- Expanded programme on immunisation (EPI)
How are new vaccination programmes implemented? (who, how and when)
- Who - to protect the vulnerable, contain outbreak, eradicate disease
What is shared decision making and why is it important?
- Conversation between patient and their health care professional to reach a health care choice together
What are the pros of vaccination? (8 points)
- Can save lives
What are the cons of vaccination? (7 points)
- Can cause serious and sometimes fatal side effects
What factors influence decision making? (6 factors)
- Lifestyle
What is the population vs individual interest debate?
- For the individual - protection by ‘herd immunity’ may be safest option as avoids risk of vaccine
Which websites can be used to find out if a person needs travel vaccines?
- NHS fitfortravel
What are some of the free and private travel vaccines available?
- Free - diphtheria, polio, tetanus, typhoid, hepatitis A, cholera
What factors should be consider when deciding to get travel vaccinations? (8 factors)
- The country or countries you’re visiting
What are the 5 common cancers (incidence) in adult men and women in the UK (list in order)?
- Breast/prostate
What are the 5 most common causes of cancer mortality for adult men and women combined in the UK (list in order)?
- Lung
What are the most common cancers in children?
Leukaemias
What is the most common causes of cancer mortality in children?
Brain, CNS and intracranial tumours
How do the patterns of cancer in the UK differ from that seen in a developing country?
Mortality is higher in UK (29%)
What is the role of legal and lifestyle changes in reducing incidence and mortality of cancer? (3 main points)
- Prevention - legal and lifestyle changes, vaccinations
What is meant by difficult (bad) news?
Bad/difficult news is defined as any news that drastically and negatively alters the patient’s (or their relatives) view of his or her future
What factors can affect the impact of news on a patient? (7 factors)
- Institutionalised beliefs
What anxieties might health care professionals have about breaking bad news? (5 points)
- Uncertainty about the patient’s expectations
What is the ABCDE method of breaking bad news?
A - Advanced preparation
What is the SPIKES method of breaking bad news?
S - Setting up
What emotions may a patient feel when they receive difficult news? (5 main emotions)
- Grief
How can cancer change partner relationships? (6 changes)
- Change in roles
What were the conclusions and consequences of the Eurocare-II report?
- Despite limitations of the methodology, cancer survival in the UK in the 1980-90s was one of the worst in Europe
What were the conclusions and consequences of the Calman-Hine report (1995)? (6 points)
(The Calman-Hine report examined cancer services in the UK, and proposed a restructuring of cancer services to achieve more equitable level of access to high levels of expertise throughout the country.)
What are the Calman-Hine solutions?
There should be 3 levels of care:
What is a national service framework? (3 main points)
- Set national standards and define service models for a service or care group
What are the main aims of the NHS cancer plan (2000)?
- Save more lives
What are the 6 key areas for action in the cancer reform strategy (2007)?
- Prevention - smoking, obesity, alcohol, etc.
Which cancers are screened for?
- Cervical
What is the national cancer survivorship initiative?
Partnership with cancer charities, clinicians and patients, considered a range of approaches to improving services and support available for cancer survivors
What were the main outcomes from ‘Improving outcomes: A strategy for cancer (2011)’? (4 outcomes)
- Prevention and early diagnosis - focus on lifestyle factors, screening, diagnostic tests
What are some of the inequalities experiences amongst cancer patients? (5 examples)
- White cancer patients report a more positive experience than other ethnic groups
What are the outcomes from the independent cancer Taskforce (2015)? (6 outcomes)
- Spearhead a radical upgrade in prevention and public health
What is body image?
- Perceptions, thoughts, and behaviours related to one’s appearance
What is biographical distribution?
- Chronic illness leads to a loss of confidence in the body
Give examples of diseases/symptoms/treatments/side-effects which affect body image (6 examples)
- Scars
What is the importance of hair?
- An important site for individual and group identity
What are the functions of the clinical record? (4 points)
- Support patient care
What should be recorded in a clinical record? (7 key aspects)
- Presenting symptoms and reasons for seeking health care
What are the differences between paper and electronic records?
- Paper - continuous, portable, writer identified, legibility issues, must be dated and signed
What is the use of records in audit, research and management?
- Support clinical audit
What is duty of care?
Legal obligation which is imposed on an individual requiring adherence to a standard of reasonable care while performing any acts that could foreseeable harm others
What is negligence?
- Negligence is a failure to exercise the care that a reasonably prudent person would exercise in like circumstances
What are the 4 ethical principles?
- Beneficence - duty to do good
What are the ethical theories? (3 main theories)
- Consequentialism/utilitarianism - the correct moral response is related to the outcome or consequence of the act
How do you evaluate an argument? (2 steps)
- Get clear on the logical form of the argument
Why might an argument be invalid? (4 reasons)
- Different premises may express different concepts
Why might an argument be unsound? (3 reasons)
- Argument is invalid
What should be avoided in arguments? (5 points)
- Straw man fallacy - simply ignoring the person’s actual position and substituting it for a distorted, exaggerated or misrepresented version of that position
What is a moral argument?
- Seek to support a moral claim of some kind
What is a deductive argument?
- Purely logic
What is an inductive argument?
Making an argument based on observation, more probable conclusions (seeing is believing but you may not have seen everything)
What are MDTs in cancer care and why are they needed?
- Modern management of cancer - involves many disciplines, surgical and non-surgical, oncology
Who is in a cancer MDT (core and extended)?
Core (medical staff):
What are the functions of MDTs in cancer care? (6 key functions)
- Discuss every new diagnosis of cancer within their site
What is sensitivity?
- True positives
What is the equation for sensitivity?
Sensitivity = true positives / (true positives + false negatives)
What is specificity?
- True negatives
What is the equation for specificity?
Specificity = true negatives / (true negatives + false positives)
What is a diagnostic test?
Any kind of medical test performed to aid in the diagnosis or detection of disease
What are the uses of diagnostic tests? (4 uses)
- Diagnosis
How is sensitivity and specificity important in informing diagnosis?
The importance of a diagnostic accuracy testing is directly proportional to the tests potential to cause patient consequences and harm
What does true positive mean?
Test indicates disease when there is disease
What does true negative mean?
Test indicates no disease when there is no disease
What does false positive mean?
Test indicates disease when there is no disease
What does false negative mean?
Test indicates no disease when there is disease
What is positive predictive value?
The probability that subjects with a positive screening test truly have the disease
What is negative predictive value?
The probability that subject with a negative screening test truly don’t have the disease
What is the likelihood ratio?
The likelihood that a given test result would be expected in a patient with the target disorder compared to the likelihood that the same result would be expected in a patient without the target disorder
What is screening?
Systematic application of a test or inquiry, to identify individuals at sufficient risk of a specific disorder to warrant further investigation or direct preventive action, amongst persons who have not sought medical attention on account of symptoms of that disorder
What is the purpose of screening? (3 purposes)
- Opportunities for primary prevention are limited
What is commonly screened for? (8 examples)
- Cancer - colorectal cancer, breast cancer, cervical cancer
What are the limitations of screening?
- Cost and use of medical resources on a majority of people who do not need treatment
What are the pros and cons of good screening?
Pros - early detection of disease means the risk of death or illness can be reduced for some people
What areas should be evaluated when deciding what should be screened for? (4 areas)
- Condition - important? epidemiology, natural history of condition, detectable risk factor, latent period, cost-effective
What is sojourn time?
- The duration of a disease before clinical symptoms become apparent but during which it is detectable by a screening test
What is length bias?
Overestimation of survival duration among screening-detected cases by the relative excess of slowly progressing cases
What are the consequences of length bias?
- Diseases with a longer sojourn time are ‘easier to catch’ in the screening net
What is lead time bias?
Overestimation of survival duration among screen-detected cases (relative to those detected by signs and symptoms) when survival is measured from diagnosis
What are the consequences of lead time bias?
- Survival is inevitably longer following diagnosis through screening because of the ‘extra’ lead time
What is over diagnosis bias?
- Overestimation of survival duration among screen-detected cases caused by inclusion of pseudo disease - subclinical disease that would not become overt before the patient dies of other causes
What is PSA testing and what can cause elevated PSA?
- Prostate-specific antigen (PSA) - protein produced by cells of the prostate gland
What are the advantages of PSA screening?
- Can help detect tumours with no symptoms
What are the disadvantages of PSA screening?
- Early detection may not reduce the chance of dying from prostate cancer
What are some of the impacts of incontinence on a patient?
- Distress
What impact might chronic dialysis have on a patient?
- Regular hospital admissions
What 4 sources are used when making a clinical decision?
- Patient preferences
What is opportunity cost?
- The loss of other alternative when one alternative is chosen
What is distributive justice?
How we distribute resources the are finite in a fair way
How can you decide ways to distribute healthcare? (5 factors)
- QALY calculation
What is confidentiality?
Pledge of agreement to not divulge or disclose information about patients to others
Why is it important to maintain confidentiality? (6 points)
- Improves trust between patient and doctor
When can confidentiality be breached?
- Statute (law)
Name some statutes (laws) that oblige doctors to disclose information
- Public Health Act 1984
Define patient safety
Coordinated efforts to prevent harm to patients cause by the process of health care itself
What is an adverse event/
Unintended event resulting from clinical care and causing patient harm
What is a near miss?
A situation in which events or omissions arising during clinical care fail to develop further
Describe the Swiss cheese model of accident causation
Although many layers of defence lie between hazards and accidents, there are flaws in each layer that, if aligned, can allow the accident to occur
What are the main causes of error at an individual and a system level?
- Individual error - errors of individuals, blames individual for forgetfulness, inattention or moral weakness
What are active failures?
- Unsafe acts committed by people in direct contact with the patient
What is latent error?
- Develop over time until they combine with other factors or active failures to casein adverse event
What are the different types of errors? (3 types)
- Knowledge based - such as forming wrong intentions or plans as a result of inadequate knowledge/experience
What are violations?
- Deliberate deviation from some regulated code of practice or procedure
What are the types of violation? (4 types)
- Routine - regularly performed shortcuts due to system, process or task being poorly designed or actions; may become tacitly accepted practice over time
What systems are in place in the NHS to try and prevent errors occurring? (3 systems)
- National Patient Safety Agency (NPSA) 2001 - coordination of reporting and learning from mistakes that affect patient safety
How do we know if a hospital is safe?
- Hospital mortality data
What situations are associated with an increased risk of error? (6 examples)
- Unfamiliarity with the task
What should we do when adverse incidents occur? (5 steps)
- Report it - incident reporting systems
Why do children go to A&E?
- Accidental injury
Why are males more likely to die than females?
- Higher suicide rates
What is the most common cause of external deaths in adolescents?
Traffic accidents (>50%)
Why does poverty increase the chance of getting ill?
- Poor nutrition
Why does poor health increase poverty?
- Reducing a family’s work productivity
What are the implications of chronic illness in children?
- Affects physical, mental and social development
What conditions are screened for before birth? (3 main tests)
Antenatal screening tests identify major abnormalities
What tests are done neonatally? (2 tests)
- Blood spot test - PKU, cystic fibrosis, sickle cell disease, congenital hypothyroidism
What are the timings for screening and developmental surveillance?
- Antenatal screening (12th week of pregnancy)
What is the purpose of the 6-8 week postnatal check?
- Take history
What is looked for in the heart examination at the 6-8 week postnatal check?
- Look for cyanosis, ventricular heave, respiratory distress, tachypnea
What is developmental dysplasia of hip (DDH)?
Ball and socket joint of hip doesn’t form properly - too shallow so femoral head is loose and can dislocate
What are the tests for developmental dysplasia of hip (DDH)?
- Barlows test - flex and adduct hip then push hip posteriorly, positive test causes femoral head to slip out of the acetabulum
What are the normal vital signs of a healthy baby?
- Respiratory rate - 30-60 breaths per minute
What immunisations should be given in the first year of life?
- 8 weeks - 6-in-1 vaccine (1st dose), rotavirus vaccine (1st dose), MenB vaccine (1st dose)
What is puerperium?
- Postnatal period
What are the main aims of antenatal care? (6 aims)
- Monitor progress of pregnancy to optimise maternal and foetal health
Which key documents influence antenatal care provisions?
- MBRRACE-UK (mothers and babies - reducing risk through audits and confidential enquiries across the UK)
What were the key themes of the national maternity review ‘Better births’? (7 themes)
- Personalised care
What tests are done at antenatal visits? (3 main tests)
- Physical examination - weight, BP, urinalysis
What are some of the risk factors for adverse outcomes to pregnancy?
- Chronic or acute disease - may be complicated with pregnancy
What are the different forms of pregnancy loss? (4 types)
- Spontaneous miscarriage - loss of pregnancy before 24 completed weeks of pregnancy
What is the MBRRACE-UK report (2014)?
- Mother and Babies Reducing Risk through Audits and Confidential Enquiries across the UK
What are common causes of death in the postnatal period? (4 causes)
- Infection
What physical health and wellbeing issues might a woman experience in the postnatal period? (9 examples)
- Perineal care - infection, inadequate repair, wound breakdown/non-healing
What mental health problems may be experienced in the postnatal period?
- 50-80% ‘The blues’ - very weepy over small things, time-limited, recovers very quickly, if it continues then begins o worry about postnatal depression
What was the main outcome of the Peel Committee Report (1970)?
Sufficient facilities should be made available for 100% of childbearing women to give birth in hospital
What are the risks associated with Caesarean section? (3 main risks)
- General anaesthesia, danger of Mendelsohns’ syndrome (aspiration pneumonia), paralytic ileus
What is the medical model of birth?
- Birth seen as a dangerous journey, only normal in retrospect, therefore assume the worst
What is the social model of birth?
Birth is seen as a normal physiological process which women are uniquely designed to achieve
What are some of the cultural issues during pregnancy?
- Unintended pregnancy - delay in seeking prenatal care and having a premature baby, higher levels of stress and depression
What was the outcome of the Midwives’ Act (1902)?
- Established normality in childbearing as the midwife’s role - refer to doctors as soon as abnormality occurs
What are the benefits of institutionalised childbirth? (5 points)
- Standardisation of care
What ar the risks of institutionalised childbirth? (5 points)
- Medicalisation
What is the role of doctors in welfare?
- You must consider the safety and welfare of children and young people, whether or not you routinely see them as patients
What are the indicators of a successful breastfeed?
- Baby - audible and visible swallowing, sustained rhythmic suck, relaxed arms and head, moist mouth, regular soaked nappies
What problems may occur with breastfeeding?
- Nipple pain
What is ‘quality’ in relation to health care?
The extent to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge
Why is there a heavy emphasis on quality management in healthcare?
Quality management produces improved quality, reduced costs, increased productivity and an increased market share
Why is consumer protection necessary? (3 medical practice deficiencies)
- Medicine has a weak evidence base
What data are available to improve patient safety? (3 sources)
- Hospital episode statistics (HES) - details referring GP, procedures given, duration of stay and discharge/death, lack of basic national data in primary care
What is the summary hospital level mortality indicator (SHMI)?
The ratio between the actual number of patients who die within 30 days of discharge compared with the number that would be expected to die on the basis of average
What are the key consumer protection agencies? (3 main ones)
- Care Quality Commission (CQC) - regulates ‘quality’ and financial performance of all health and social care providers, public and private, provides regulatory framework, license all providers of health and social care
Who enforces the NICE guidelines?
- Royal colleges
How can consumer protection be improved?
- Appraisal by peers
What is clinical governance?
A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish
What are the types of neglect? (4 types)
- Physical neglect
What are the signs of neglect? (7 examples)
- Malnutrition, begging, stealing or hoarding food
What are the 4 types of child abuse?
- Physical abuse - deliberate aggressive actions on the child that inflict pain
Who are the people involved in reproductive ethic debates? (3 main parties)
- Parents - procreative autonomy, parents wishes regarding reproductive choice should be respected, state interference should be minimal
What was the main outcome of the human fertilisation and embryology act (1990)?
A woman shall not be provided with fertility treatment services unless account has been taken of the welfare of any child who may be born as a result of the treatment (including the need of that child for a father)’
What were some of the criticisms of the ‘welfare criterion’? (3 main criticisms)
- Fertile couples don’t have to meet this criterion
What was the main outcome of the human fertilisation and embryology act (2008)?
Continues to talk about a duty to take account the welfare of the child in providing fertility treatment (hence, welfare criterion remains) but replaces reference to ‘the need for a father’ with ‘the need for supportive parents’, thus valuing role of all parents
What is the pro-life argument?
- Abortion ends the life of a foetus.
What is procreative autonomy?
- To have control over one’s reproductive capabilities
What did the abortion act (1967, amended 1990) state?
A person shall not be guilty of an offence under the law relating to abortion when pregnancy is terminated by a registered medical practitioner if two registered medical practitioners are of the opinion, formed in good faith:
What are the arguments for assisted reproduction? (4 arguments)
- Procreative autonomy
What are the arguments against assisted reproduction? (7 arguments)
- Involves destruction of embryos
What is pre-implantation genetic diagnosis and what are the associated ethical issues?
- Genetic profiling of embryos prior to implantation 9as a form of embryo profiling), and sometimes even oocytes prior to fertilisation
What provisions, if any, should be made for doctors who conscientiously object - what are the 3 views?
- Objections should always be respected - the autonomy of the medical provider is paramount, no-one should be made to do something that goes against their strongly held personal beliefs
Which act says a 16 year old has full capacity?
The Family Law Reform Act of 1969
What is Gillick competency?
Child (under 16) can consent to medical treatment if deemed competent by medical professional, without need for parental permission or knowledge
What are Fraser guidelines?
Doctor can give contraceptive advice and treatment to a person under 16 if they are mature and intelligent, likely to continue to have sex, and if the treatment is in their best interests
What should you do before conducting an intimate examination? (5 steps)
- Explain to the patient why an examination is necessary and give the patient an opportunity to ask questions
What is the role of the midwife in postnatal care? (7 key points)
- Screening/identification of actual and/or ‘at risk’ patients
What are the aims from NICE postnatal care up to 9 weeks after birth guidelines (2006, updated 2015)?
- A documented, individualised postnatal care plan for every woman
Who is in the pregnancy MDT? (7 roles)
- Midwives
What is the role of MDT postnatal care and support teams?
Postnatal care should be a continuation of the care the woman received during her pregnancy, labour and birth, and involve planning and regularly reviewing the content and timing of care, for individual women and their babies
What are some of the barriers to MDT work?
- Separate documentation
What is the importance of research-informed practice? (5 points)
- Personal experience is biased in various ways
What is the research cycle?
- Identify a clinical problem
What is the implementation gap?
Gap between scientific understanding and patient care
What are the barriers to implementation of research-informed practice? (4 barriers)
- Characteristics of the recommendations - easy to follow, compatible with existing norms, need for new skills, complexity of recommendations
What is quality improvement (QI)?
Facilitate the uptake and continuing use of evidence-based policy and practice, focusing on recurrent problems within system of care to improve:
What does quality improvement involve? (5 aspects)
- Engage participants across organisational levels
Give some examples of quality improvement initiatives
- Revision of professional roles
What makes a quality improvement initiative effective? (3 aspects)
- Passive dissemination of information, such as distribution of educational materials or didactic lectures, is generally ineffective in driving change
What is quality and outcomes framework (QOF)?
- Annual reward and incentive programme detailing GP practice achievement results
Does quality and outcomes framework work?
- Improvements associated with financial incentives seem to be achieved at the expense of small detrimental effects on aspects of care that were not incentivised
What was the aims of national commission for quality and innovation (CQUINs) 2014-15?
- Friends and family test - incentivise high performing providers
What is the incidence of falls in the elderly?
- 35% of 65-79 year olds
What are the possible consequences of falls?
- Osteoporotic fractures
What are the risk factors for falls?
- Muscle weakness
How can falls be prevented/decrease risk?
- Increase activity - diversity of physical activity
What doesn’t help reduce falls?
- Brisk walking
What is QALY?
- Quality adjusted life year
What is the cost of falls for the NHS each year?
£1.3 billion
What is the cost of hip fractures for the NHS each year?
- £12,000 per patient
What is a common fracture in elderly people?
Fracture of the neck of femur
What are the two types of fracture of the neck of femur?
- Extracapsular - the bone outside the joint capsule breaks; fixed with sliding hip screw, intramedullary nail
What is avascular necrosis?
- Death of bone tissue due to lack of blood supply
What is the main risk factor associated with increased risk of fracture?
Osteoporosis
What are the risk factors for hip fractures? (10 examples)
- Low bone mineral density (BMD) is associated with increased fracture risk
How can hip fractures be prevented?
- Fall prevention
What is primary prevention?
Avoidance of disease before any signs or symptoms develop
What is secondary prevention?
Avoidance of progression or later problems, signs or symptoms present
What would be primary and secondary prevention be in relation to stroke?
- Primary - no history of stroke or TIA
What is the prevention paradox?
- The majority of people who suffer a stroke are not at high risk of stroke (e.g. 75% have ‘normal’ blood pressure)
What are the effects of targeting population for prevention?
- Large potential benefit to community
What are the effects of targeting high risk groups for prevention?
- Larger potential benefit to individual
Which group of people are at the highest risk from stroke?
- people who have already had one - secondary prevention reduces risk in these people
What medication is used for secondary prevention of strokes?
- Ischaemic - clopidogrel, statins, anti-hypertensives, anticoagulant if AF
What percentage of people who have strokes are under 50 years old?
<20%
What is the incidence in strokes in men and women?
- Men are at a 25% higher risk of having stroke and at a younger age compared to women
What are the non-modifiable risk factors for stroke?
- Age
What are the modifiable risk factors for strokes? (6 factors)
- High blood pressure - biggest risk factor
What did the PROGRESS trial show?
Reducing blood pressure after stroke reduces risk of stroke recurrence
What are the barriers for initiating medical therapies for conditions with no obvious symptoms? (6 barriers)
- Misinformed
What is a confounding factor?
- Distortion of the relationship between an exposure and outcome due to shared relationship with something else
How can we limit confounding factors and what are the effects? (4 strategies)
- Restriction - limit the participants of your study who have possible confounders; means that you have less data and difficult with multiple confounders
What is standardisation?
Way to limit confounding, often used to control for differences in age groups when comparing rates of disease in two populations with different age structures
What is standardised mortality ratio (SMR)?
Ratio between the observed number of deaths in a study population to the number of expected deaths
What is direct standardisation?
Required we know the age-specific rates of mortality in all populations under study
What is indirect standardisation?
Only requires that we know the total number of deaths and the age structure of the study population
Why do we have waiting lists?
- There is a limitless demand for health, people can always ‘be more healthy’ which created high demand
Why are waiting times important to patients? (5 examples)
- The patient’s condition may deteriorate while waiting and in some cases the effectiveness of the proposed treatment may be reduced
How can you measure waiting times? (3 methods)
- Average waiting times (mean or median)
What are the theories of NHS waiting lists?
- The backlog - implies a need for occasional emergency injection of funds
How can the NHS reduce waiting times? (4 methods)
- Manage demand - ensuring each referral represents the most appropriate decision for the care of the individual patient
What was the 2002-2008 policy ‘targets and terror’?
- Performance management of Trusts and PCTs based on achievement of target waiting times
What are the pros of ‘targets and terror’ policy?
- No inpatients waiting longer than 3 months
What were the cons of ‘targets and terror’ policy?
- Sacrifice of professional autonomy - managers pressuring doctors, may be forced to treat les urgent due to waiting times
What is possible criteria for priority on a waiting list? (6 examples)
- Clinical urgency
What are the social consequences of deafness?
- Social impact - difficult to have conversations, isolation, intimacy issues, problems at work
How can a stroke affect communication?
- Aphasia (and sometimes dysphasia) - difficulty in the generation of speech and sometimes also in its comprehension
What are the social consequences of speech and communication difficulties?
- Not being able to express yourself clearly can be very isolating
What areas can medico-legal implications occur in a person with epilepsy?
- Determination of fitness to drive and other similarly dangerous activities
What are the rules for whether people can drive with epilepsy?
- Group 1 which applies to cars, motorbikes, and most other small vehicles - need to be seizure free for 12 months
What are CAMs?
- Complementary - non-mainstream practice is used together with conventional medicine
What are the 5 big CAMs?
- Acupuncture - fine needles are inserted at certain sites in the body for therapeutic or preventative purposes
What is the underlying principle with CAMs?
- Self-healing is triggered
What percentage of CAMs are covered by the NHS?
10%
What are the barrier to CAMs on the NHS? (5 main barriers)
- Regulatory issues
Why should CAMs be provided by the NHS? (5 arguments)
- Patient choice
Which complementary therapy is most used for MSK problems?
Osteopathy
What is osteopathy used mainly to treat? (5 problems)
- Back pain
What do chiropractors mainly treat?
- Back, neck and shoulder problems
What is acupuncture used to treat?
- MSK patients
Why are people using acupuncture?
Effectiveness gap - a clinical area where available treatments are not fully effective or satisfactory for various reasons including lack of efficacy, adverse effects and acceptability to patients
What is the evidence base for acupuncture?
- Acupuncture correlated with physiological parameters i.e. with decreases in brain flow
What are the criticisms of acupuncture?
- Is the effect too small and not clinically relevant?
What does the NICE guidelines state about acupuncture in lower back pain, osteoarthritis, and headaches?
- Lower back pain - consider manual therapy, do not offer acupuncture
What are the 5 categories for significant impaired decision making ability?
- Lack of insight - person suffers from some disability but seem unaware of the existence of their disability
Why is it important to support patients decision making? (5 reasons)
- Patients generally happier if they can make decisions
How might doctors assist patients in making decisions? (4 methods)
- Using a different form of communication
Which act are capacity determinants governed by?
Mental capacity act (2005)
According to the mental capacity act, when does a person lack capacity?
A person lacks capacity if they are unable to:
What are the 5 key principles of the mental capacity act?
- Presumption of capacity - a person must be assumed to have capacity until proven otherwise; assumption can be over-ridden if shown to lack capacity for that decision at that time
How many people in the UK have dementia?
Approximately 850,000 people
How might dementia first present?
- Patient noticing changes - forgetfulness, difficulty with names and finding the right word, embarrassment in social situations
What is the impact of diagnosis of dementia on a patient?
- Denial (with or without insight) - patient attributes all problems to old age, often accompanied by anger at the suggestion that there is anything wrong
What determines the response of the patient to the diagnosis of dementia?
- Insight and stage of illness - ability to remember and process information
What is the impact of diagnosis on the carers?
- Confirmation of something they have long suspected
What determines the response of the carer to the diagnosis?
- understanding of illness
What are the benefits of diagnosis?
- Know what it is that you are dealing with
Describe the effect of dementia on the patient, spouse/partner, children and carers
- Patient - loss of self-esteem, may find communication difficult, loss of independence and autonomy, change in social roles and relationships, impact on ADLs
How much of the cost of dementia is paid by people with dementia and their families?
2/3 = £17.4 billion
What percentage of carers don’t receive enough support?
43%
Why are people with dementia at high risk of elder abuse? (3 main reasons)
- More vulnerable
What are examples of advanced care planning?
- Advanced statement of wishes - wishes and preferences about treatment/care they would like (NOT legally binding hence can use best interests judgement)
What are advanced directives?
- Extends patient autonomy to apply in situations where they don’t have capacity as defined under the MCA 2005
What are advanced directives valid and applicable?
- Patient is 18+ - note MCA is for 16+ but only 18+ can refuse treatment
What is Ulysses arrangement?
Advanced directive for bipolar disorder
What are the pros of advanced directives?
- Respect patient autonomy
What are the cons of advanced directives?
- Difficulty to verify if the patient’s opinion has changed since making AD
What are some of the research atrocities in history?
- Nazi medical experiments (Nuremberg trials)
What is the Nuremberg Code (1947)?
The Nuremberg code resulted from the Nuremberg trials. It was an early code for research ethics principles, including:
What is the Helsinki declaration (1964)?
Includes requirement that any human research is subject to independent ethical review and oversight by properly convened committee
What are some research ethics principles? (6 examples)
- Usefulness - valid, good method, hasn’t been done before, strong justification
What is valid consent?
Voluntary, informed, patient is competent
What does voluntary consent mean?
- Not putting pressure on patients or volunteers
What should patients be given to facilitate consent?
- Information sheets
What is confidentiality and why it is important?
- Confidentiality is the state of keeping or being kept secret or private
How can we increase the level of confidentiality?
- Limit access to identifiable information
What is an ethics committee?
Body responsible for ensuring that medical experimentation and human research are carried out in an ethical manner in accordance with national and international law
Why do we need ethics approval? (5 reasons)
- To protect participants
When is ethics approval needed? (3 examples)
- Research involves humans
What are some of the types of research ethics committees?
- NHS research ethics committees
What does the human tissue act (2004) state about research?
- Consent for storage and use of tissue for ‘scheduled purposes’ is required for tissues from living or deceased persons
What percentage of deaths does CHD cause in the UK?
- 29% men
Why are the death rates falling from CHD?
- Risk factors improved - fewer smokers, cholesterol better controlled, HTN controlled
What is the effect of health inequalities on CHD?
Lower social class at higher risk - health behaviours
What are the non-modifiable risk factors for CHD?
- Elevated blood cholesterol
What is risk?
The probability of an event in a given time period
What is the equation for risk ratio?
Risk ratio = risk for exposed / risk for non-exposed
What is the equation for risk difference?
Risk difference = Risk for exposed - Risk for non-exposed
What is odds ratio?
A ratio of the odds of an event in an exposed group to the odds of the same event in a group that is not exposed
What is the equation for odds ratio?
OR = ad/bc
What is population attributable risk?
The risk of disease will increase as the exposure prevalence or relative risk increases
What is the leading cause for cancer mortality?
Lung cancer
What are the main risk factors associated with lung cancer?
- Smoking
What percentage of lung cancer cases are cause by smoking?
90%
What is the second leading cause of lung cancer after smoking?
Radon
What are the different types of lung cancer?
- Small cell (13%)
How many people in the world are infected with TB?
1/4 of the world population = approx. 2 billion people
How many deaths per year does TB cause (million)?
1.5 million people (in 2020 according to WHO)
What are the factors associated with recent increases in the prevalence of TB? (4 main factors)
- Urban homelessness
What time of year does TB incidence peak?
Spring/summer
What can be done to address rising rates of TB?
- Put more people on ART
What is the prevention paradox?
A preventative measure that brings large benefits to the community offers little to each participating individual
What are the pros of ‘high risk’ approaches to health promotion?
- Appropriate to individual
What are the cons of ‘high risk’ approaches to health promotion?
- Screening is difficult
What are the pros of ‘population’ approaches to health promotion?
Large potential as targeting many people
What are the cons of ‘population’ approaches to health promotion?
- Population paradox - small perceived individual benefit
What are some examples of occupational lung disease?
- Occupational asthma
How have occupational health risks changed over time?
- Better environmental control an health and safety - e.g. from mid 20th century with coal mining, etc.
What is occupational asthma?
Like other types of asthma, it is characterised by airway inflammation, reversible airways obstruction, and bronchospasm, but it is caused by something in the workplace environment
Give some examples of occupations that are at a higher risk for occupational asthma
- Bakers
What history would you expect from a patient with occupational asthma?
- Symptoms worse at work and better away from work e.g. weekends and holidays
Give some occupational causes of COPD
- Coal mining
What is pneumoconiosis?
Occupational restrictive lung disease caused bye inhalation of dust (coal dust, silica, asbestos)
What is simple coal workers pneumoconiosis?
- After around 10 years of coal mining, small nodules are present
What are possible complications with coal workers pneumoconiosis?
- Occurs in coal workers especially fi the coal they work with is heavily contaminated with silicates
What is silicosis?
- Occupational lung disease caused by inhalation of crystalline silica dust, and is marked by inflammation and scarring in the form of nodular lesions in the upper lobes of the lung
What is siderosis?
- Deposition of iron in tissue
What is acute pneumonitis?
- Acute inhalation of a substance that causes symptoms immediately
What is hypersensitive pneumonitis?
- Type 3 hypersensitivity reaction (immune complex deposition)
What are some causes of hypersensitive pneumonitis?
- Bird fancier’s lung - due to feathers and bird droppings
What percentage of lung cancers in men are related to occupation?
10%
What is asbestos?
- A natural occurring silicate mineral
What are the 2 types of asbestos fibres?
- Serpentine - curly, white asbestos (relatively harmless), cleared with mucociliary escalator
What is mesothelioma?
- Cancer of the mesothelium almost inevitably caused by occupational exposure asbestos
Where are claims submitted for compensation for occupational illness in the UK?
Disability benefits centre of benefits agency (DSS)
What is decision analysis?
Systematic and quantitative way of making healthcare decisions e.g. when presented with two options
What does decision analysis assume?
- Decision process is logical and rational
What are the stages ind decision analysis? (4-5 stages)
- Structure the problem as a decision tree - identifying choice, information (what is and is not known) and preferences
What do squares and circles mean on decision trees?
- Squares - indicated decision, represents choice between actions
How do you calculate expected utility?
Expected utility = utility value x probability
What is sensitive analysis?
Sensitive analysis explores what would happen if the probabilities or utility values were slightly different to the ones you are using - calculate effect of uncertainty on decision
What are preference sensitive and probability sensitive decisions?
- Preference sensitive - the person might feel strongly about the side effects of the treatment
What are the benefits of using decision analysis to make decisions? (5 benefits)
- Makes all assumptions in a decision explicit
What are the negatives of using decision analysis to make decisions?
- Probability estimates - required data sets to estimate probability may not exist; subjective probability estimates are subject to bias
What is the ICF model of disability?
Functioning and disability are multi-dimensional concepts relating to:
What is palliative care?
- Active holistic care of patients with advanced progressive illness
What are the goals of palliative care? (8 goals)
- Improves quality of life
Who is general palliative care given to?
Core aspect of care for all patients and their families with advanced disease by all health professionals
Who is specialised palliative care for?
Patients (and carers) with unresolved symptoms and complex psychosocial issues, with complex end-of-life and bereavement issues
Who provides specialised palliative care?
- NHS - community/hospital clinic nurse specialist, some consultants, some inpatient units, macmillan
What is end of life care?
- Branch of palliative care - caring for people who are nearing the end of life
What are some of the challenges for the future of palliative care?
- Inequality of service provision and standards
What is ‘total pain’?
Recognises pain as being physical, psychological, social and spiritual
What are the different types of nurses involved in palliative care? (4 main types)
- District nurse - primary health care team, community based, generic palliative care skills, ‘hands on’ nursing skills
Where is the preferred place of death?
- Most people wish to die at home
What percentage of admission notes document the CPR decisions?
10%
What percentage of in-hospital CPR is not appropriate?
40-50%
What is DNACPR?
Do Not Attempt CPR - decision made and recorded in advance, applies to those present if a person subsequently suffers sudden cardiac arrest or dies
What are Bowlby’s 4 stages of grief?
- Numbness
What are the symptoms of grief?
- Sadness, anger, guilt, anxiety, loneliness, fatigue, helplessness, shock, yearning, numbness
What is Warden’s tasks of mourning? (4 tasks)
- Accepting the reality of the loss e.g. come to terms with the person being ‘gone’
What factors affect the severity of grief? (6 factors)
- Closeness of relationship
What is spirituality?
Umbrella term that includes religious/faith frameworks, but it also includes the meaning of life, purpose, sense of personhood
How can religious beliefs impact on bereavement?
- Belief in an afterlife - the continuing existence of the loved one and possibility of meeting up again
What is pathological grief?
- Extended grief reactions - getting stuck in one of the phases (normally each phase is about 6 months)
What is the myth of the neutral therapist?
- Idea that psychotherapists will ‘leak’ their personal views regardless of their intention
What are CDSS?
Clinical decision support system - designed to aid clinician decision making
What are the different types of CDSS?
- Computerised
What are some examples of CDSS? (4 examples)
- Reminder systems - screening, vaccination, testing, medication use
What are the effects of computer support on prescribing? (6 main effects)
- Reduced time to achieve therapeutic stabilisation
Do CDSS work?
- Can improve practitioner performance in diagnosis, disease management, prescribing/drug dosing, rates of vaccination, screening, etc.
What are patient decision aids?
- Help patient understand probable outcomes of options
What is the key issue with patient decisions aids?
No consensus on what information should be included in a patient decision aid
What improves practice when using decision support? (4 examples)
- Providing decisions support as part of the clinician workflow
What are potential barriers to using CDSS? (4 examples)
- Earlier negative experience of IT
What are potential facilitators of CDSS?
- Self-control of CDSS
What is food poisoning?
Diarrhoea and vomiting with or without pain
What are the major causes of food poisoning?
- Not cooking food thoroughly (particularly meat)
What are some microbial infections that cause food poisoning?
- Bacterial - salmonella, campylobacter, shigella, C. difficile
What are some toxins that cause food poisoning?
- Bacterial toxins - clostridium perfringens, s. aureus, clostridium botulinum
What are some chemicals that cause food poisoning?
- Heavy metals
What is the most common cause of food poisoning?
Campylobacter
Describe the clinical picture of salmonella infection (transmission, incubation, symptoms)
- Transmission - ingestion of contaminated food, faecal contaminations, person-person, infected animals
Describe the clinical picture of staphylococcus aureus infection (transmission, incubation, symptoms)
- transmission - contaminated food by skin/nasal flora
Describe the clinical picture of cryptosporidium infection (transmission, incubation, symptoms)
- Transmission - animal-human, person-person, contaminated water or land, associated with foreign travel
Describe the clinical pictures of escherichia coli infection (transmission, incubation, symptoms)
- Transmission - contaminated food, person-person
Describe the clinical picture of norovirus infection (transmission, incubation, symptoms)
- Transmission - faecal-oral route, environmental contamination, contaminated food and water
Describe the clinical picture of clostridium perfringens infection (transmission, incubation, symptoms)
- Transmission - contaminated cooked meat and poultry
Describe the clinical picture of campylobacter infection (transmission, incubation, symptoms)
- Transmission - raw/undercooked meat, unpasteurised milk, bird-pecked milk, untreated water, domestic pets with diarrhoea, person-person
How can food poisoning be prevented?
- Isolation
What is ‘safe food’?
Food that will not cause harm to a person who consumes the food when it is prepared, stored and/or eaten according to its intended use
What are concerns with food?
- Food borne illness
What does the public health act state about food poisoning?
Allows exclusions from work of people that pose increased risk of GI infection spread - children in nursery/pre-school, people who work with food, health and social care staff, people with doubtful hygiene
What are some of the offences under the food safety act (1990)? (3 examples)
- The sale of food that has been rendered injurious to health, is unfit for human consumption or is so contaminated that it would not be reasonable to expect it to be used for human consumption
What is hazard analysis critical control point?
- Analysis of the potential food hazards in a food business (e.g. microbiological, chemical & foreign matter contamination)
What are the objectives in food poisoning outbreaks? (3 objectives)
- Reduce the number of primary and secondary cases
What are the investigations done in food poisoning outbreaks?
- Preliminary phase - is there an outbreak? confirming the diagnosis, what is the nature and extent of the outbreak?
What are outbreak outliers?
- Outliers are cases at the very beginning and end that may not appear to be related
What might outbreak outliers represent? (6 examples)
- Baseline level of illness
How can analytical epidemiological studies be useful to identify probable food source of outbreak?
- Compare food history of ill and well persons
Which GI cancers are prevalent in which populations?
- Oesophageal - Middle East and Chine
What dietary intake increase the risk of colorectal cancer?
Fat intake
What is the evidence base for ‘5-a-day’?
- Evidence from observational epidemiology that average fruit/veg intake of less than 200g associated with increased risk of cancer, but possibly little additional benefit beyond 400g/day
Describe the relationship between beta carotene and cancer
- Beta carotene found in fruit/vegetables
What are the problems with measuring diet?
- Random error - diet varies and difficulties in measurement, people don’t eat the same things everyday and individual consumptions vary significantly
What are the different measures of diet?
- Food disappearance data
What are the pros and cons of food frequency qeustionnaires?
- Pros - captures usual diet and less work to code/complete
What are the pros and cons of diet diaries?
- Pros - records diet as eaten (over limited period), better estimate of energy and absolute intake, more flexible
What are the main dietary associations with cancer? (7 examples)
- Oesophageal - alcohol, obesity
What is the trend of alcohol consumption in the UK?
- Per capita consumption in the UK is lower than many European countries
What percentage of men and women have an alcohol use disorder?
- 38% of men and 16% of women (16-64) have an alcohol use disorder (approximately 8 million people)
Where is identification and brief advice (IBA) delivered?
Delivered in a range of setting - primary and secondary care but also community setting (pharmacies, community health-oriented events)
What specialised treatment is available for alcohol problems? (4 examples)
- CBT - common
Which medical conditions are wholly attributable to alcohol?
- Alcoholic liver disease
What are some of the social consequences of alcohol consumption?
- Death - declining since 2008
What are effective, moderately effective and less effective policies for alcohol related health promotion?
More effective policies:
What are the key UK departments involved in alcohol policy? (2 main departments)
- Home office (focus on public disorder)
What was the ‘alcohol strategy (2021)’?
- Minimum unit price policy dropped, multi-buy promotion offers were not banned as suggested
What is efficiency?
- Target resources to those activities that give the greatest health gain for the money spent as this will maximise population health gain for the money spent as this will maximise population health gain
What is allocative efficiency?
Investing in healthcare are interventions that are worthwhile
What is technical efficiency?
Investing in health care interventions which make the best use of scarce resources
What is equity in financing?
- Geographic allocation of funding by weighted capitation
What is the class equality/inequality in health care?
Evidence of social class equality in the use of primary care and social class inequality in the use of secondary care
What is the concept of the ‘margin’?
The incremental change in resources (inputs and their cost) committed to an activity that produces an incremental change in effects (improved patient outcomes)
Why is the margin important?
- Incremental investments in an activity may be associated with diminishing returns
Why do we need economic evaluation?
- Values both inputs (opportunity costs) and outputs (health outcomes) of any intervention
How do you measure cost?
- Cost to NHS - NICE perspective, cost of drug, cost of delivery
How do you measure benefit?
Health gain = increase in length + QoL
What is cost-minimisation analysis?
Chooses cheapest option between treatments that have identical outcomes
What is cost-effective analysis?
- Costs and outcomes are combined into a single measures e.g. reduction in blood pressure
What is cost-utility analysis?
- Combines multiple outcomes into a single measure (QALY) using QoL instruments e.g. EQ5D
What is cost-benefit analysis?
Puts cost and benefit into monetary/numerical terms, e.g. how much is the 3 months gained worth to the patient?
When can cost-effectiveness analysis be used?
- If the outcome measures are just clinical
What are the levels of resource allocation decisions?
- Macro (societal) level - regarding health funding vs education or funding of certain drugs
What are the arguments for and against age-based rationing being applied to macro-level resource allocation decisions?
- For - treatment and care of elderly people is very costly so ‘cost-effective’ argument might require resources elsewhere
Describe the Fair-innings argument (1997)
- Older people had a long life already, therefore fairer to divert resources to younger people
What are the contraindications to the Fair-innings argument?
- treating on the basis of need might mean older people don’t receive lower priority
What are the arguments for and against age-based rationing being applied to micro-level resource allocation decisions?
- For - age should be relevant because older people are less likely to respond to treatment and have a poorer prognosis in general due to increased complication risk
What is age discrimination?
Unjustifiable difference in treatment based solely on age
What is the difference between direct and indirect age discrimination?
- Direct - direct difference in treatment based on age, cannot be justified
What is the GMC and laws view on age discrimination?
- GMC - must not unfairly discriminate against patients or let views about patient affects decisions
How do calculate QALY?
- Assign a utility value (0-1) to a state of health and then multiply by the number of years expected to live in this state
What leads to utilitarian justification?
QALYs focus on overall likely outcomes of resource allocations
What type of healthcare do you have when the cost per QALY is low/high?
- Low - high priority, efficient health care
What are the arguments for QALY-based assessments?
- Maximises healthcare based on quality and quantity of life
What are the arguments against QALY-based assessments?
- Difficulties in measuring - how do you measure quality or value or life? who makes the decisions? introduces bias
What is relationship between age and QALY?
- The older you are the fewer QALYs you will gain due to lower life expectancy & co-morbidities
What body appraises medical technologies in pounds per QALY?
NICE
What is PICO?
Population
What are the 3 discrete steps in critical appraisal?
- Are the results of the study valid?
What is study validity and what should you look for?
Study validity is the believability or credibility of the results
What are the different types of results?
- Therapy - look at relative risk reduction, absolute risk reduction, odds ratio, number needed to treat, confidence intervals
How should you apply the results of a critical appraisal?
- How similar are the patients to the study to your patient?
What do randomised control trials look at?
Look at new treatment, often a drug - compares to current gold standard or placebo
How is randomisation done?
- Enveloped
